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Andrusiów S, Pawlak Z, Stańczykiewicz B, Bogunia-Kubik K, Koszewicz M. Chronic inflammatory demyelinating polyradiculoneuropathy in patients with diabetes mellitus - treatment with intravenous immunoglobulins: A systematic review. Biomed Pharmacother 2023; 164:114974. [PMID: 37290187 DOI: 10.1016/j.biopha.2023.114974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a rare disease, but it is one of the most common inflammatory neuropathies in the population. It is particularly common among patients with diabetes mellitus. This raises many problems, both with the differential diagnosis of diabetic and inflammatory neuropathy, as well as the choice of treatment. Intravenous immunoglobulin (IVIG) is one of the therapeutic options. There is evidence for the effectiveness of IVIG in treating about two-thirds of patients. However, no review has been published to date systematising studies evaluating the response to IVIG treatment in patients with CIDP and coexisting diabetes. METHODS The present study is based on the PRISMA statement and is registered at PROSPERO (CRD42022356180). The study included searches of the databases of MEDLINE, ERIC, CINAHL Complete, Academic Search Ultimate and Health Source: Nursing/Academic Edition, finally including seven original papers evaluating a total of 534 patients in the review. The main inclusion criteria were the presence of a group of patients with CIDP and comorbid diabetes in the study. RESULTS The systematic review showed a lower efficacy of IVIG treatment among patients with coexisting diabetes compared with idiopathic CIDP (61 % vs 71 %). In addition, the presence of conduction blocks on neurography and shorter disease duration proved to be significant factors improving response to treatment. CONCLUSIONS Current scientific data do not allow for strong recommendations on the choice of treatment for CIDP. A randomised, multicentre study evaluating the efficacy of different therapeutic approaches to this disease entity needs to be planned.
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Affiliation(s)
- Szymon Andrusiów
- Department of Neurology, Wroclaw Medical University, Wroclaw, Poland.
| | - Zuzanna Pawlak
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - Bartłomiej Stańczykiewicz
- Division of Consultation Psychiatry and Neuroscience, Department of Psychiatry, Wroclaw Medical University, L. Pasteura 10, 50-367 Wroclaw, Poland
| | - Katarzyna Bogunia-Kubik
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
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Chen Y, Tang X. Chronic Inflammatory Demyelinating Polyradiculoneuropathy in Association With Concomitant Diseases: Identification and Management. Front Immunol 2022; 13:890142. [PMID: 35860284 PMCID: PMC9289227 DOI: 10.3389/fimmu.2022.890142] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/27/2022] [Indexed: 11/17/2022] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a rare, heterogeneous, but treatable autoimmune-mediated peripheral neuropathy characterized by demyelination. CIDP can occur independently or simultaneously with a variety of diseases such as diabetes, monoclonal gammopathy of undetermined significance (MGUS), connective tissue disease, and HIV. It is important to identify CIDP and specific peripheral neuropathies caused by these diseases; this review aims to summarize the CIDP literatures related to diabetes, MGUS, SLE, and HIV, and to be helpful for the management of such patients.
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Valentin M, Coultas R, Sottile E. Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) in Diabetes Mellitus: A Diagnostic Dilemma. Cureus 2022; 14:e25332. [PMID: 35774650 PMCID: PMC9236626 DOI: 10.7759/cureus.25332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 11/08/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a neurological disorder of the peripheral nerves which can lead to gradually increasing motor and sensory loss. It can be a difficult entity to diagnose, particularly in elderly patients with a history of Diabetes Mellitus due to their overlapping neuropathic syndromes. Reported is a case of CIDP in an elderly female who manifested multiple sensory, motor, and autonomic complaints. A compilation of clinical features, neuroimaging, lumbar puncture, electromyography, nerve conduction studies, and nerve biopsy were used to reach the diagnosis. Highlighted is a clinical approach to identifying CIDP that can cause neuropathy in the setting of other potential confounding disorders namely Diabetes Mellitus.
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Dziadkowiak E, Moreira H, Wieczorek M, Budrewicz S, Barg E, Koszewicz M. Correlations between Electrophysiological Parameters, Lymphocyte Distribution and Cytokine Levels in Patients with Chronic Demyelinating Inflammatory Polyneuropathy. J Pers Med 2021; 11:jpm11080766. [PMID: 34442410 PMCID: PMC8399760 DOI: 10.3390/jpm11080766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/30/2021] [Accepted: 07/31/2021] [Indexed: 11/23/2022] Open
Abstract
The goal of this study was to analyse, in relation to electrophysiological results, the distribution of lymphocyte subpopulations and the level of cytokines in patients with the typical form of chronic demyelinating inflammatory polyneuropathy (CIDP) before immunoglobulin treatment. The study group consisted of 60 patients (52 men, eight women), with a mean age 64.8 ± 11.2, who fulfilled the diagnostic criteria for the typical variant of CIDP, with (23 patients) and without (37 patients) diabetes mellitus. We analysed the results of the neurophysiological tests, and correlated them with the leukocyte subpopulations, and cytokine levels. In CIDP patients, IL-6, IL-2, IL-4 and TNF-α levels were significantly increased compared to the control group. Fifty patients had decreased levels of T CD8+ lymphocytes, and 51 patients had increased levels of CD4+ lymphocytes. An increased CD4+/CD8+ ratio was also found. Negative correlations were observed mainly between compound muscle action potential (CMAP) amplitudes and cytokine levels. The study enabled the conclusion that electrophysiological parameters in CIDP patients are closely related to the autoimmune process, but without any clear differences between patients with and without diabetes mellitus. Correlations found in the study indicated that axonal degeneration might be independent of the demyelinating process and might be caused by direct inflammatory infiltration.
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Affiliation(s)
- Edyta Dziadkowiak
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (E.D.); (S.B.)
| | - Helena Moreira
- Department of Basic Medical Sciences, Wroclaw Medical University, Borowska 211, 50-556 Wroclaw, Poland; (H.M.); (E.B.)
| | - Malgorzata Wieczorek
- Faculty of Earth Sciences and Environmental Management, University of Wroclaw, Uniwersytecki 1, 50-137 Wroclaw, Poland;
| | - Slawomir Budrewicz
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (E.D.); (S.B.)
| | - Ewa Barg
- Department of Basic Medical Sciences, Wroclaw Medical University, Borowska 211, 50-556 Wroclaw, Poland; (H.M.); (E.B.)
| | - Magdalena Koszewicz
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (E.D.); (S.B.)
- Correspondence: ; Tel.: +48-71-734-31-00
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Dohrn MF, Winter N, Dumke C, Bähr F, Ouwenbroek A, Hoppe B, Reiners K, Dafotakis M. Stellenwert klinischer, funktioneller und bildgebender Diagnostik zur Früherkennung, Differenzialdiagnose und Verlaufskontrolle diabetischer Neuropathien. KLIN NEUROPHYSIOL 2021. [DOI: 10.1055/a-1335-1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ZusammenfassungVon weltweit mehr als 400 Mio. Menschen mit Diabetes mellitus entwickeln bis zu 50% im Laufe ihrer Erkrankung eine Neuropathie. Trotz oder gerade wegen dieser Häufigkeit darf jedoch nicht jede Neuropathie, die in Koinzidenz mit einem Diabetes mellitus auftritt, unkritisch als diabetische Neuropathie diagnostiziert werden. Eine präzise Ausschluss- und Ausmaßdiagnostik ist entscheidend, um andere behandelbare Erkrankungen wie z. B. die Chronisch Inflammatorische Demyelinisierende Polyradikuloneuropathie oder die hereditäre Transthyretin-Amyloidose nicht zu übersehen. Einfache, nicht-invasive, preiswerte und allzeit verfügbare Screeningmethoden stellen Anamnese und klinische Untersuchung dar. Ergänzend ist in frühen Erkrankungsstadien die Quantitativ Sensorische Testung hilfreich zur Eingrenzung einer Small Fiber-Dysfunktion. Sind, typischerweise im Verlauf, große Nervenfasern geschädigt, so ist das charakteristische elektrophysiologische Bild das einer längenabhängigen, axonalen, sensibel betonten oder sensomotorischen Neuropathie. Die Nervensonografie kann zur Unterscheidung von autoimmun-demyelinisierenden Neuropathien hilfreich sein. Moderne Untersuchungsverfahren wie die MR-Neurografie können auch proximale Nervenabschnitte bis auf Faszikelebene darstellen, sind allerdings nur an wenigen Zentren verfügbar. Haut- und Nervenbiopsien sind v. a. bei untypischen Verläufen zur Abgrenzung von Differenzialdiagnosen hilfreich. Diabetische Neuropathien können zu einer erheblichen Reduktion von Lebensqualität und Lebensdauer führen. Zur frühest- und bestmöglichen ursächlichen und symptomatischen Therapieeinleitung ist eine präzise Diagnostik essentiell.
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Affiliation(s)
- Maike F. Dohrn
- Neurologie, Uniklinik der RWTH Aachen, Aachen, Deutschland
| | - Natalie Winter
- Neurologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | | | | | | | - Barbara Hoppe
- Neurologie, Klinikum Köln-Merheim, Köln, Deutschland
| | - Karlheinz Reiners
- Neurologie, Hermann-Josef-Krankenhaus Erkelenz, Erkelenz, Deutschland
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Weerasinghe D, Veerapandiyan A, Stanton M, Herrmann DN, Akmyradov C, Logigian E. Recovery of foot drop in chronic inflammatory demyelinating polyneuropathy (CIDP). Muscle Nerve 2021; 64:59-63. [PMID: 33876440 DOI: 10.1002/mus.27253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/11/2021] [Accepted: 04/17/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION/AIMS Foot drop is common in chronic inflammatory demyelinating polyneuropathy (CIDP), but its prognosis is uncertain. METHODS CIDP patients with less than anti-gravity strength (<3/5 power) of ankle dorsiflexion (ADF) on Medical Research Council manual muscle testing on presentation at our center were identified by retrospective review. After initiation of standard treatment, ADF power was serially tabulated, and predictors of recovery were determined. RESULTS Of the 27 identified patients, ADF power at presentation was <3/5 in 48/54 legs. At 1 y after treatment, ADF power improved to >/= 3/5 in 17/27 patients in one (N = 6) or both (N = 11) legs. On multi-variate analysis, predictors of recovery of ADF power were tibialis anterior compound muscle action potential amplitude at presentation, shorter disease duration, and female gender. DISCUSSION Foot drop improves to anti-gravity power in most treated CIDP patients depending in part on the severity of fibular motor axon loss at onset of treatment.
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Affiliation(s)
- Dinushi Weerasinghe
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Aravindhan Veerapandiyan
- Division of Neurology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Michael Stanton
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - David N Herrmann
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Chary Akmyradov
- Biostatistics Core, Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Eric Logigian
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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COVID-19 as a Trigger of Recurrent Guillain-Barré Syndrome. Pathogens 2020; 9:pathogens9110965. [PMID: 33228253 PMCID: PMC7699516 DOI: 10.3390/pathogens9110965] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/11/2020] [Accepted: 11/17/2020] [Indexed: 02/06/2023] Open
Abstract
Coronavirus 2019 (COVID-19) has been reported to trigger Guillain-Barré syndrome (GBS). While uncommon, recurrent GBS (rGBS) episodes, triggered by antecedent viral infections, have been reported in a small proportion of GBS patients, here we describe a patient with a recurrent case of GBS, occurring secondary to COVID-19 infection. Before this patient's episode, he had two prior GBS flares, each precipitated by a viral infection followed by complete recovery besides intermittent paresthesias. We also consider the nosology of this illness in the spectrum of rGBS and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), with their differing natural histories, prognosis, and therapeutic approaches. For patients who have a history of inflammatory demyelinating polyradiculopathies who develop COVID-19, we recommend close observation for neurologic symptoms over the next days and weeks.
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Rajabally YA, Peric S, Cobeljic M, Afzal S, Bozovic I, Palibrk A, Basta I. Chronic inflammatory demyelinating polyneuropathy associated with diabetes: a European multicentre comparative reappraisal. J Neurol Neurosurg Psychiatry 2020; 91:1100-1104. [PMID: 32868389 DOI: 10.1136/jnnp-2020-322971] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/27/2020] [Accepted: 06/16/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The association between chronic inflammatory demyelinating polyneuropathy (CIDP) and diabetes is uncertain despite important diagnostic and management implications. METHODS We retrospectively analysed two European cohorts, totaling 257 patients with 'definite' or 'probable' CIDP, from Serbia and Birmingham, UK. RESULTS Diabetes was present at CIDP diagnosis in 25/139 (18%) subjects in the Serbian cohort and in 23/118 (19.5%) in the UK cohort. In both cohorts, diabetes prevalence was higher than local general population prevalence rates (RR: 2.09; 95% CI 1.39 to 2.95 and RR: 2.22; 95% CI 1.46 to 3.17, respectively). Considering typical CIDP only, diabetes prevalence was greater than expected in both cohorts (RR: 2.58; 95% CI 1.60 to 3.82 and RR: 2.68; 95% CI 1.71 to 3.87, respectively). CIDP with diabetes occurred later in life than CIDP without diabetes (58.96 years, SD: 11.09 vs 51.71 years, SD: 16.02; p=0.003) and presented more frequently in the typical form than in patients without diabetes (79.2% vs 61.2%; p=0.02). Baseline Inflammatory Neuropathy Cause and Treatment disability scores were similar in patients with and without diabetes (p=0.90). Proportions of treatment responders were similar in both groups (70% vs 74.9%; p=0.65), as were response amplitudes (p=0.87). DISCUSSION Our results, both for all CIDP and typical CIDP presentations, support a twofold increased relative risk of diabetes compared with the general population. CIDP with diabetes appears to present older and more frequently in the typical form, as compared with CIDP without diabetes. CIDP with diabetes appears similar to CIDP without diabetes in disability levels at diagnosis and probability, as well as amplitude of treatment response.
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Affiliation(s)
- Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, University Hospitals of Birmingham, Birmingham, UK .,Aston Medical School, Aston University, Birmingham, United Kingdom
| | - Stojan Peric
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Mina Cobeljic
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Saadia Afzal
- Inflammatory Neuropathy Clinic, University Hospitals of Birmingham, Birmingham, UK
| | - Ivo Bozovic
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksa Palibrk
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Basta
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
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Patel K, Horak H, Tiryaki E. Diabetic neuropathies. Muscle Nerve 2020; 63:22-30. [DOI: 10.1002/mus.27014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 06/20/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Kamakshi Patel
- Department of Neurology, University of Texas Medical Branch Galveston Texas USA
| | - Holli Horak
- Department of Neurology, University of Arizona Tucson Arizona USA
| | - Ezgi Tiryaki
- Department of Neurology, University of Minnesota Minneapolis Minnesota USA
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Abstract
There is a growing realization that many patients are incorrectly diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP), with at least half of patients that carry a diagnosis of CIDP in the USA possibly having a different explanation for their neuropathy or having no neuropathy at all. Many misdiagnosed patients go on to receive costly and potentially harmful treatments for a disease that they do not have, while at the same time missing an opportunity to treat their true ailment. The cost of misdiagnosis on patients and society is not trivial. Many factors contribute to misdiagnosis. Particular points of vulnerability include the evaluation of "atypical" CIDP, interpretation of equivocal nerve conduction studies, over-reliance on elevations in cerebrospinal fluid protein concentration in indeterminate ranges, and placing excessive diagnostic weight on subjective changes following the initiation of immunotherapy. In addition to heighted awareness of the challenges, adherence to CIDP diagnostic guidelines, utilization of objective metrics to document clinical change, and referrals to CIDP centers of excellence are strategies that may improve diagnostic accuracy.
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Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, USA.
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Memon AB, Madani S, Ahmad BK, Grover K, Arcila-londono X, Schultz L, Sripathi N. Value of terminal latency index and sensory electrophysiology in idiopathic and diabetic chronic inflammatory demyelinating polyradiculoneuropathy. Clin Neurophysiol Pract 2019; 4:190-193. [PMID: 31886444 PMCID: PMC6920505 DOI: 10.1016/j.cnp.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 08/13/2019] [Accepted: 08/23/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES To evaluate sensory electrophysiology, terminal latency index (TLI), and treatment response in idiopathic and diabetic chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). METHODS We performed a retrospective review of 147 patients with CIDP who underwent electrodiagnostic evaluation (January 2000-December 2015). Eighty-nine patients fulfilled electrophysiological criteria described by the Ad hoc Subcommittee of the American Academy of Neurology and Albers et al. Fifty-eight patients were divided into idiopathic (N = 40) and diabetic (N = 18) groups. These groups were compared for age, sex, cerebrospinal fluid protein, response to treatment, sensory response abnormalities, and TLI measurements using chi-square tests for binary and categorical variables and using t-tests and mixed-effects models for continuous variables. RESULTS The difference in abnormal rates of sensory responses was significant for the sural nerve, with the idiopathic group having a lower rate than the diabetic group (80% vs. 100%, p < 0.001). No group differences in the TLI measurements were significant. CONCLUSIONS Sural sensory responses may have some value in differentiating idiopathic CIDP from diabetic CIDP. Larger prospective studies are needed to confirm our findings. SIGNIFICANCE Our study suggests that abnormal sural sensory potentials may have some significance in differentiating idiopathic CIDP from diabetic CIDP.
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Affiliation(s)
- Anza B. Memon
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA,Wayne State University, School of Medicine, Detroit, MI, USA,Corresponding author at: 2799 W Grand Blvd, Detroit, Michigan 48202, USA.
| | - Sarah Madani
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA
| | | | - Kavita Grover
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA,Wayne State University, School of Medicine, Detroit, MI, USA
| | - Ximena Arcila-londono
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA,Wayne State University, School of Medicine, Detroit, MI, USA
| | - Lonni Schultz
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA
| | - Naganand Sripathi
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA,Wayne State University, School of Medicine, Detroit, MI, USA
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Breiner A, Barnett Tapia C, Lovblom LE, Perkins BA, Katzberg HD, Bril V. Randomized, controlled crossover study of IVIg for demyelinating polyneuropathy and diabetes. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:6/5/e586. [PMID: 31454771 PMCID: PMC6943235 DOI: 10.1212/nxi.0000000000000586] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/28/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine whether IV immunoglobulin (IVIg) is more effective than placebo at reducing disability in patients with diabetes and demyelinating polyneuropathy features. METHODS This is a double-blinded, single-center, randomized, controlled crossover trial of IVIg treatment vs placebo. The primary outcome measure was the mean change in Overall Neuropathy Limitation Scale (ONLS) scores during the IVIg phasecompared with the placebo phase. Secondary outcomes include changes in the Rasch-built Overall Disability Scale, Medical Research Council sum scores, grip strength, electrophysiologic measurements, quality of life, and adverse effects. RESULTS Twenty-five subjects were recruited between March 2015 and April 2017. The mean change in ONLS scores was -0.2 points during the IVIg phase and 0.0 points during the placebo phase (p = 0.23). Secondary outcomes did not show significant differences between IVIg and placebo. CONCLUSIONS IVIg did not reduce disability, improve strength, or quality of life in patients with demyelinating polyneuropathy features and diabetes after 3 months of treatment in comparison with placebo. Therefore, careful consideration of the primary diagnosis is required before immunomodulatory therapy. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients with diabetes and demyelinating polyneuropathy features, IVIg did not significantly reduce disability.
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Affiliation(s)
- Ari Breiner
- From the Division of Neurology (A.B.), Department of Medicine, the Ottawa Hospital; Ottawa Hospital Research Institute (A.B.); Division of Neurology (C.B., H.D.K., V.B.), Department of Medicine, Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto; Division of Endocrinology and Metabolism (L.E.L., B.A.P.), Department of Medicine, Mount Sinai, Hospital and Lunenfeld Tanenbaum Research Institute, University of Toronto, Canada; and Institute for Research and Medical Consultations (V.B.), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Carolina Barnett Tapia
- From the Division of Neurology (A.B.), Department of Medicine, the Ottawa Hospital; Ottawa Hospital Research Institute (A.B.); Division of Neurology (C.B., H.D.K., V.B.), Department of Medicine, Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto; Division of Endocrinology and Metabolism (L.E.L., B.A.P.), Department of Medicine, Mount Sinai, Hospital and Lunenfeld Tanenbaum Research Institute, University of Toronto, Canada; and Institute for Research and Medical Consultations (V.B.), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Leif Erik Lovblom
- From the Division of Neurology (A.B.), Department of Medicine, the Ottawa Hospital; Ottawa Hospital Research Institute (A.B.); Division of Neurology (C.B., H.D.K., V.B.), Department of Medicine, Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto; Division of Endocrinology and Metabolism (L.E.L., B.A.P.), Department of Medicine, Mount Sinai, Hospital and Lunenfeld Tanenbaum Research Institute, University of Toronto, Canada; and Institute for Research and Medical Consultations (V.B.), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Bruce A Perkins
- From the Division of Neurology (A.B.), Department of Medicine, the Ottawa Hospital; Ottawa Hospital Research Institute (A.B.); Division of Neurology (C.B., H.D.K., V.B.), Department of Medicine, Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto; Division of Endocrinology and Metabolism (L.E.L., B.A.P.), Department of Medicine, Mount Sinai, Hospital and Lunenfeld Tanenbaum Research Institute, University of Toronto, Canada; and Institute for Research and Medical Consultations (V.B.), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hans D Katzberg
- From the Division of Neurology (A.B.), Department of Medicine, the Ottawa Hospital; Ottawa Hospital Research Institute (A.B.); Division of Neurology (C.B., H.D.K., V.B.), Department of Medicine, Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto; Division of Endocrinology and Metabolism (L.E.L., B.A.P.), Department of Medicine, Mount Sinai, Hospital and Lunenfeld Tanenbaum Research Institute, University of Toronto, Canada; and Institute for Research and Medical Consultations (V.B.), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Vera Bril
- From the Division of Neurology (A.B.), Department of Medicine, the Ottawa Hospital; Ottawa Hospital Research Institute (A.B.); Division of Neurology (C.B., H.D.K., V.B.), Department of Medicine, Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto; Division of Endocrinology and Metabolism (L.E.L., B.A.P.), Department of Medicine, Mount Sinai, Hospital and Lunenfeld Tanenbaum Research Institute, University of Toronto, Canada; and Institute for Research and Medical Consultations (V.B.), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Kim SW, Kim EH, Lee J, Choi YC, Kim SM, Shin HY. Risk of osteoporosis in patients with chronic inflammatory neuropathy- a population-based cohort study. Sci Rep 2019; 9:9131. [PMID: 31235735 PMCID: PMC6591220 DOI: 10.1038/s41598-019-45591-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 05/30/2019] [Indexed: 12/16/2022] Open
Abstract
The risk of osteoporosis in patients with chronic inflammatory neuropathy (CIN) has not been evaluated in detail. We conducted a population-based case-control study nested in a retrospective cohort to analyze osteoporosis risk among patients with CIN using a nationwide database. Patients with CIN based on the Korean Classification of Disease diagnostic code were included and were matched to controls. A Cox proportional hazards regression model was used to evaluate the effect of CIN on osteoporosis. After propensity score matching, 585 CIN patients and 585 controls were selected. Patients with CIN had an increased osteoporosis risk (hazard ratio [HR] = 2.293, 95% confidence interval [CI] 1.460-3.601) compared with controls. The osteoporosis risk was higher among male patients with CIN than among male controls (HR = 5.404, 95% CI 2.252-12.969), while there were no significant differences among women. Among the CIN patients, the average daily dose of corticosteroids was higher in those who developed osteoporosis (19.6 mg [10.8-49.3]) than those who did not (16.2 mg [7.2-29.1], p = 0.001). The osteoporosis risk among CIN patients is higher than among controls. High risk of osteoporosis in male patients may indicate that osteoporosis in CIN patients results from the disease itself or related treatments.
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Affiliation(s)
- Seung Woo Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Eun Hwa Kim
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Jinae Lee
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Young-Chul Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.
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Tan CY, Arumugam T, Razali SNO, Yahya MA, Goh KJ, Shahrizaila N. Nerve ultrasound can distinguish chronic inflammatory demyelinating polyneuropathy from demyelinating diabetic sensorimotor polyneuropathy. J Clin Neurosci 2018; 57:198-201. [PMID: 30145079 DOI: 10.1016/j.jocn.2018.08.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 08/13/2018] [Indexed: 12/14/2022]
Abstract
Diabetic patients with poor glycaemic control can demonstrate demyelinating distal sensorimotor polyneuropathy (D-DSP) on electrophysiology. Distinguishing D-DSP from chronic inflammatory demyelinating polyneuropathy (CIDP) can be challenging. In this study, we investigated the role of nerve ultrasound in differentiating the two neuropathies. Nerve ultrasound findings of D-DSP patients (fulfilling the electrophysiological but not clinical criteria for CIDP) were compared with non-diabetic CIDP patients (fulfilling both criteria). We studied 108 and 95 nerves from 9 D-DSP and 10 CIDP patients respectively. CIDP patients had significantly larger cross-sectional areas of the median nerve at the mid-arm (17.0 ± 12.5 vs 8.7 ± 2.6; p = 0.005), ulnar nerve at the wrist (7.3 ± 3.1 vs 4.1 ± 1.0; p = 0.001), mid forearm (8.8 ± 5.3 vs 5.5 ± 1.5; p = 0.002) and mid-arm (14.5 ± 14.1 vs 7.5 ± 1.9; p = 0.013), and radial nerve at mid forearm (4.1 ± 2.4 vs 1.2 ± 0.4; p < 0.001). In comparison to D-DSP, CIDP patients had markedly larger nerves at the proximal and non-entrapment sites of the upper limbs, suggesting that nerve ultrasound is useful in differentiating the two neuropathies.
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Affiliation(s)
- Cheng-Yin Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Thaarani Arumugam
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Siti Nur Omaira Razali
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Mohd Azly Yahya
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Khean-Jin Goh
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Nortina Shahrizaila
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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Allen JA, Ney J, Lewis RA. Electrodiagnostic errors contribute to chronic inflammatory demyelinating polyneuropathy misdiagnosis. Muscle Nerve 2017; 57:542-549. [DOI: 10.1002/mus.25997] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Jeffrey A. Allen
- Department of NeurologyUniversity of Minnesota, 12‐150 Phillips Wangensteen Building, 516 Delaware StreetMinneapolis Minnesota55455 USA
- Department of NeurologyNorthwestern UniversityChicago Illinois USA
| | - John Ney
- Department of NeurologyBoston UniversityBoston Massachusetts USA
| | - Richard A. Lewis
- Department of NeurologyCedars‐Sinai Medical CenterLos Angeles California
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Rajabally YA, Stettner M, Kieseier BC, Hartung HP, Malik RA. CIDP and other inflammatory neuropathies in diabetes — diagnosis and management. Nat Rev Neurol 2017; 13:599-611. [DOI: 10.1038/nrneurol.2017.123] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Bril V, Blanchette CM, Noone JM, Runken MC, Gelinas D, Russell JW. The dilemma of diabetes in chronic inflammatory demyelinating polyneuropathy. J Diabetes Complications 2016; 30:1401-7. [PMID: 27389526 PMCID: PMC5528142 DOI: 10.1016/j.jdiacomp.2016.05.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 05/03/2016] [Accepted: 05/06/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE We reviewed the literature on chronic inflammatory demyelinating polyneuropathy (CIDP) in diabetes mellitus (DM) and explored real-world data on the prevalence and treatment of CIDP within DM. METHODS A literature search of Scopus was performed for the terms chronic inflammatory demyelinating polyradiculoneuropathy, chronic inflammatory demyelinating polyneuropathy, CIDP, and prevalence, incidence, epidemiology, or diabetes; peripheral neuropathy and prevalence or diabetes. We also searched through the reference lists of the resulting publications for additional findings that may have been missed. Additional publications on guidelines for the diagnosis of CIDP and diabetic neuropathy were also included. A descriptive analysis of the 2009-2013 PharMetrics Plus™ Database was performed to estimate the prevalence and treatment of CIDP within the DM population. RESULTS There is an increasing body of literature suggesting that the prevalence of CIDP tends to be higher in diabetic patients, especially in those of older age. Our real-world data seem to support published findings from the literature. For the total cohort (N=101,321,694), the percent prevalence of CIDP (n=8,173) was 0.008%; DM (n=4,026,740) was 4%. The percent prevalence of CIDP without DM (n=5,986) was 0.006%; CIDP with DM (n=2,187) was 9-fold higher at 0.054%. For patients >50years old, there was a significantly higher percentage of CIDP with DM than CIDP without DM. Approximately 50% of CIDP patients were treated with IVIg, 23%-24% with steroids, 1%-2% with PE, and 20%-23% received no treatment. CONCLUSIONS In addition to the growing evidence of higher prevalence of CIDP in DM, our findings reinforce the need for heightened awareness of the association of CIDP and DM.
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Affiliation(s)
- Vera Bril
- Division of Neurology, University of Toronto, 200 Elizabeth St, 5EC-309, TGH, Toronto, ON, M5G 2C4, Canada
| | - Christopher M Blanchette
- Department of Public Health Sciences, University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC 28223, USA
| | - Joshua M Noone
- Department of Public Health Sciences, University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC 28223, USA
| | - M Chris Runken
- Department of Medical Affairs, Grifols, 79 TW Alexander Dr. Bldg 4101 Research Commons, Research Triangle Park, NC 27709, USA
| | - Deborah Gelinas
- Department of Medical Affairs, Grifols, 79 TW Alexander Dr. Bldg 4101 Research Commons, Research Triangle Park, NC 27709, USA
| | - James W Russell
- Department of Neurology, University of Maryland School of Medicine, and VA Maryland Health Care System, 110S Paca Street, 3S-129, Baltimore, MD, 21201, USA.
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Abstract
Electrophysiologic studies provide objective data concerning nerve and muscle function. This information enables the diagnosis of disease states and monitoring of disease progression. This chapter describes the changes in electrophysiologic function in both prediabetes and diabetes and discusses the utility of this testing in patients with diabetes. Both the strengths and limitations of electrophysiology are discussed.
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Abraham A, Alabdali M, Qrimli M, Albulaihe H, Breiner A, Barnett C, Katzberg HD, Lovblom LE, Perkins BA, Bril V. Treatment Responsiveness in CIDP Patients with Diabetes Is Associated with Higher Degrees of Demyelination. PLoS One 2015; 10:e0139674. [PMID: 26461125 PMCID: PMC4603787 DOI: 10.1371/journal.pone.0139674] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/16/2015] [Indexed: 12/25/2022] Open
Abstract
Introduction Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is one of several chronic treatable acquired demyelinating neuropathies. Objectives To explore the association between the degree of demyelination in CIDP, and treatment responsiveness. Methods A retrospective chart review of CIDP subjects assessed between 1997 and 2013 was performed to compare treatment responsiveness using different sets of criteria. Results 99 CIDP patients were included, 34 with diabetes mellitus (DM). Treatment responsiveness was higher in CIDP-DM fulfilling 1 or more EFNS/PNS criteria, (63% vs. 31%, p = 0.03), and in CIDP+DM fulfilling 2 or more criteria (89% vs. 36%, p = 0.01). Nonetheless, treatment responsiveness in CIDP+DM had the highest odds ratio (3.73, p = 0.01). Similar results were also shown in simplified uniform study criteria, with 10% cut off values for CIDP-DM, compared to 30% for CIDP+DM. Conclusion In CIDP+DM, higher degrees of demyelination are associated with treatment responsiveness, implying the need to adjust current criteria in these patients.
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Affiliation(s)
- Alon Abraham
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Majed Alabdali
- Department of Neurology, King Fahad Hospital of the University, University Of Dammam, Dammam, Saudi Arabia
| | - Mohammad Qrimli
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Hana Albulaihe
- Department of Neurology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Ari Breiner
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Hans D. Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Leif E. Lovblom
- Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai, Hospital and Lunenfeld Tanenbaum Research Institute, University of Toronto, Toronto, Canada
| | - Bruce A. Perkins
- Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai, Hospital and Lunenfeld Tanenbaum Research Institute, University of Toronto, Toronto, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
- * E-mail:
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Abraham A, Breiner A, Katzberg HD, Lovblom LE, Perkins BA, Bril V. Treatment responsiveness in CIDP patients with diabetes is associated with unique electrophysiological characteristics, and not with common criteria for CIDP. Expert Rev Clin Immunol 2015; 11:537-46. [PMID: 25764107 DOI: 10.1586/1744666x.2015.1018891] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Characterize treatment responsiveness in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients with diabetes mellitus (DM). METHODS We performed a retrospective chart review of CIDP subjects assessed between 1997 and 2013 and compared treatment response rates in those with and without DM, using different sets of criteria. RESULTS 99 CIDP patients were included, 34 CIDP+DM and 65 CIDP-DM patients, both having similar treatment response rates. CIDP patients fulfilling European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria had higher treatment response rates. Responders fulfilled a higher number of American Academy of Neurology (AAN) and EFNS/PNS criteria and had a higher number of demyelinating features in the total cohort and in CIDP-DM but not in CIDP+DM patients. CIDP+DM responders, however, had unique electrophysiologic characteristics. CONCLUSION Fulfilling EFNS/PNS and AAN criteria, and higher number of demyelinating features, are associated with higher treatment response rates in CIDP-DM but not in CIDP+DM patients, implying the need for adjusting current criteria to predict treatment response rates in CIDP-DM patients.
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Affiliation(s)
- Alon Abraham
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada
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21
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Névoret ML, Vinik AI. CIDP variants in diabetes: measuring treatment response with a small nerve fiber test. J Diabetes Complications 2015; 29:313-7. [PMID: 25466645 DOI: 10.1016/j.jdiacomp.2014.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/27/2014] [Accepted: 10/29/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Chronic inflammatory demyelinating polyneuropathy (CIDP) is eleven times more common among people with diabetes than the general population and is treatable with appropriate immunotherapy. Treatment response is usually measured clinically (symptomatic and functional improvement). We present a case of a patient with type 2 diabetes (T2D) and CIDP whose treatment response was measurable with the Sudoscan sudomotor function test. This test may represent a new objective evaluation of the treatment of CIDP. CASE DESCRIPTION The patient is a 60year old male initially referred to our center in August 2012, at which time he was diagnosed with CIDP based on AAN electrodiagnostic criteria (NCS). Autonomic functions were significant for low heart rate variability response to expiration/inspiration (E/I), Valsalva maneuver and the ratio of the RR interval for the 30th to the 15th beat upon standing (1.08, 1.12, 1.05 respectively), and frequency analysis of the total spectral power, the standard deviation of the normal RR intervals (sdNN) and their root mean squared (rmsSD). Sudoscan electrochemical skin conductances (ESC), measuring small nerve fiber function on the palms and soles, were very low: 23 μS in the feet and 32 μS in the hands. After one cycle of intravenous immunoglobulin (IVIG: 6 doses total, 75g each) the patient had no change in symptoms of burning, numbness, shooting pains, and gait impairment. However, E/I, Valsalva, and 30:15 ratios (1.19, 1.36, 1.39 respectively) were improved, as were NCS. Sudoscan scores for feet and hands were unchanged (23 μS and 32 μS). In March 2013, the patient's autonomic functions worsened (E/I, Valsalva, and 30:15 ratios 1.1, 1.07, 1.12 respectively), but feet and hand ESC started to show improvement (35 μS and 52 μS respectively). Azathioprine was started. Eight days after a second cycle of IVIG in January 2014, the patient reported for the first time less burning, shooting pains and tingling. E/I, Valsalva, and 30:15 ratios remained low (1.03, 1.07, and not analyzable, respectively), while foot and hand ESC scores continued to improve (43 μS and 55 μS respectively). DISCUSSION CIDP diagnosis and treatment response are difficult in the diabetic patient. We found that NCS and autonomic function tests did not correlate well with clinical status while numerical Sudoscan scores matched closely symptomatic changes. ESC have been found to correlate well with peripheral small fiber function and neuropathic symptoms in DPN. The findings in this patient warrant further investigation of the use of Sudoscan to monitor CIDP response to therapy.
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Lozeron P. [Atypical neuropathies associated with diabetes]. Rev Neurol (Paris) 2014; 170:837-42. [PMID: 25459114 DOI: 10.1016/j.neurol.2014.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 04/04/2014] [Accepted: 04/11/2014] [Indexed: 11/16/2022]
Abstract
Diabetes is the leading cause of neuropathy worldwide and, due to the epidemic progression of the affection, prevalence of diabetic neuropathies will increase in the near future. Beside the typical diabetic neuropathy pattern and the common entrapment neuropathies, several unusual clinical forms have been described with either a symmetrical or an asymmetrical pattern. Treatment-induced neuropathy is an acute sensory affection most commonly related to acute glycemic control. Pain is debilitating and associated with vegetative dysfunction. Prevention is important, as resolution is often incomplete. Several patterns or asymmetrical neuropathies of inflammatory and ischemic origin were described long ago in the lower limb. They are debilitating, most often painful and require steroid treatment. Other patterns affecting the thoracolumbar region or the upper limbs or involving a painless motor deficit must be identified as specific treatments are sometimes needed. An association between diabetes and chronic inflammatory demyelinating polyneuropathy has not been demonstrated but diagnosis may be suggested due to the misleading low conduction velocities seen in classical diabetic neuropathy. Like any other patient, the diabetic patient may present a neuropathy unrelated to diabetes. To facilitate patient care, neurologists should be aware of such clinical entities.
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Affiliation(s)
- P Lozeron
- Inserm U965, service de physiologie clinique, université Paris-Diderot, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France.
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Dunnigan SK, Ebadi H, Breiner A, Katzberg HD, Barnett C, Perkins BA, Bril V. The characteristics of chronic inflammatory demyelinating polyneuropathy in patients with and without diabetes--an observational study. PLoS One 2014; 9:e89344. [PMID: 24586703 PMCID: PMC3929752 DOI: 10.1371/journal.pone.0089344] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/20/2014] [Indexed: 12/25/2022] Open
Abstract
Introduction We aimed to determine whether the clinical characteristics and electrodiagnostic classification of nerve injury, and response to treatment differed in patients diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP) with and without diabetes. Methods CIDP patients with diabetes (CIDP+DM) (n = 67) and without diabetes (CIDP-DM) (n = 67) underwent clinical examination and nerve conduction studies (NCS). CIDP-DM patients were selected using age and gender matching with the existing CIDP+DM cohort. Patients treated with immunotherapies were classified as responders (R) (n = 46) or non-responders (NR) (n = 54) based on clinical response to treatment. The groups were compared using analysis of variance, contingency tables and Kruskal-Wallis analyses. Results CIDP+DM subjects had more severe neuropathy based on higher lower limb vibration potential thresholds (VPT)(p = 0.004), higher Toronto Clinical Neuropathy Score (TCNS) (p = 0.0009), more proximal weakness (p = 0.03), more gait abnormality (p = 0.03) and more abnormal NCS. CIDP+DM subjects had more abnormal sural NCS with lower sural sensory nerve action potential amplitudes (2.4±3.0 µV, 6.6±6.0 µV, p<0.0001) and slower sural nerve conduction velocities (38.6±5.4 m/s, 41.0±5.3 m/s, p = 0.04). CIDP-DM subjects were more likely to receive immune therapies (93% vs 57%, p = <0.0001), despite no significant differences in treatment responder rates (p = 0.71). Patients who responded to therapy had shorter duration of CIDP than non-responders (8.0±6.0 y vs 11.9±7.6 y, p = 0.004). Discussion The clinical phenotype and electrophysiological profile of CIDP patients differs according to the presence or absence of diabetes. Despite CIDP+DM patients having more severe clinical and electrophysiological neuropathy, they are less likely to receive disease-modifying/specific therapy, yet have similar response rates to treatment as those without diabetes. Specifically, the duration of neuropathy - not diabetes status - was associated with treatment response.
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Affiliation(s)
- Samantha K. Dunnigan
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Hamid Ebadi
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Ari Breiner
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Hans D. Katzberg
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Carolina Barnett
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Bruce A. Perkins
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Canada
| | - Vera Bril
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
- * E-mail:
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Kaplan RL, Albers JW. Treatment of chronic inflammatory demyelinating polyneuropathy. Expert Rev Neurother 2014; 3:233-46. [DOI: 10.1586/14737175.3.2.233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Chan YC, Wilder-Smith E. Predicting treatment response in chronic, acquired demyelinating neuropathies. Expert Rev Neurother 2014; 6:1545-53. [PMID: 17078793 DOI: 10.1586/14737175.6.10.1545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic inflammatory demyelinating polyradiculopathy is an immune-mediated neuropathy that was first described approximately 30 years ago. Since that time an increasingly wide spectrum of chronic acquired demyelinating polyneuropathies exhibiting different phenotypes, clinical course and treatment responses to immunomodulatory treatment have been described. Several new therapeutic agents have been prescribed for such conditions, some with promising results. This review summarizes what is presently known about the clinical courses, treatment responses and predictors of response of the chronic inflammatory demyelinating polyradiculopathy subgroups.
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Affiliation(s)
- Yee-Cheun Chan
- National University Hospital, Division of Neurology, 5 Lower Kent Ridge Road, 119074 Sinagpore.
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Abstract
Diabetic radiculoplexus neuropathies (DRPN) are neuropathies clinically and pathologically distinct from the neuropathy typically associated with diabetes (DPN). DRPN are usually subacute in onset, painful, and often demonstrate a monophasic course with incomplete recovery. Pathologically, these neuropathies are due to ischemic injury from altered immunity and often have features suggestive or diagnostic of microvasculitis. Unlike DPN, immune therapy may be helpful in treatment of these conditions given their pathological substrate and therefore are important to identify early and distinguish from other neuropathies that occur in patient with diabetes.
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Affiliation(s)
- Ruple S Laughlin
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA.
| | - P James B Dyck
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA; Peripheral Neuropathy Research Laboratory, Mayo Clinic Rochester, Rochester, MN, USA
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28
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Breiner A, Brannagan TH. Comparison of sensitivity and specificity among 15 criteria for chronic inflammatory demyelinating polyneuropathy. Muscle Nerve 2013; 50:40-6. [PMID: 24338746 DOI: 10.1002/mus.24088] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 09/08/2013] [Accepted: 10/01/2013] [Indexed: 12/14/2022]
Affiliation(s)
- Ari Breiner
- Division of Neurology; University of Toronto, Toronto General Hospital; Toronto Ontario Canada
| | - Thomas H. Brannagan
- Columbia University, Neurological Institute; 710 West 168th Street, Box 163 New York New York 10032 USA
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Abstract
Peripheral neuropathy is an important factor of disability in the elderly, which is significant now that up to 20% of the population is older than 60 years in industrialized countries. Potentially treatable neuropathies including primary inflammatory polyneuropathies and systemic disorders, especially vasculitic neuropathies, are as common in this age group as in younger patients. Neuropathies associated with diabetes, malignancy, and monoclonal gammopathies are even more common in these patients. It is thus essential to identify the causes of these neuropathies in this group of patients and treat them whenever feasible.
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Said G, Krarup C. Chronic inflammatory demyelinative polyneuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:403-13. [PMID: 23931792 DOI: 10.1016/b978-0-444-52902-2.00022-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic inflammatory demyelinative polyneuropathy (CIDP) is an acquired polyneuropathy presumably of immunological origin. It is characterized by a progressive or a relapsing course with predominant motor deficit. The diagnosis rests on the association of non-length-dependent predominantly motor deficit following a progressive or a relapsing course associated with increased CSF protein content. The demonstration of asymmetrical demyelinating features on nerve conduction studies is needed for diagnosis. The outcome depends on the amplitude of axon loss associated with demyelination. CIDP must be differentiated from acquired demyelinative neuropathies associated with monoclonal gammopathies. CIDP responds well to treatment with corticosteroids, intravenous immunoglobulins, and plasma exchanges, at least initially.
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Affiliation(s)
- Gérard Said
- Department of Neurology, Hôpital de la Salpêtrière, Paris, France.
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Padua L, Stålberg E, Caliandro P, Muscogiuri G, Pazzaglia C, Sorice GP, Granata G, Salomone E, Pontecorvi A, Giaccari A. Single-fiber conduction velocity test allows earlier detection of abnormalities in diabetes. Muscle Nerve 2011; 43:652-6. [PMID: 21484824 DOI: 10.1002/mus.21935] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The purpose of this study was to determine whether single-fiber conduction velocity (SF-CV) of a small number of axons increases sensitivity for identification of motor nerve conduction alterations in patients with diabetes. METHODS Twenty-one consecutive diabetic patients in good metabolic control were studied. For each patient, conventional (C-CV) and SF-CV results were correlated with the presence of neuropathic symptoms. RESULTS Nine of 21 patients reported symptoms suggestive of mild nerve impairment. Three patients had abnormal sural nerve CV, 1 of whom also had abnormal motor nerve conduction. Eighteen patients had normal findings on conventional tests, 3 of whom had slowing of SF-CV. CONCLUSIONS SF-CV is able to detect mild myelin damage with higher sensitivity than conventional tests. The use of SF-CV may be a helpful tool in the early identification of diabetic polyneuropathy, and it may be useful for tailoring an approach to diabetic polyneuropathy.
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Affiliation(s)
- Luca Padua
- Institute of Neurology, Università Cattolica del Sacro Cuore, Largo F Vito 1, Rome 00168, Italy.
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Stephanova DI, Krustev SM, Negrev N, Daskalova M. The myelin sheath aqueous layers improve the membrane properties of simulated chronic demyelinating neuropathies. J Integr Neurosci 2011; 10:105-20. [PMID: 21425485 DOI: 10.1142/s0219635211002646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 01/21/2011] [Indexed: 11/18/2022] Open
Abstract
Recently, patients with chronic demyelinating neuropathies have demonstrated significant abnormalities in their multiple nerve excitability properties measured by a non-invasive threshold tracking technique. In order to expand our studies on the possible mechanisms underlying these abnormalities, which are not yet well understood, we investigate the contributions of the aqueous layers within the myelin sheath on multiple membrane properties of simulated fibre demyelinations. Four degrees of systematic paranodal demyelinations (two mild demyelinations termed PSD1 and PSD2, without/with aqueous layers respectively, and two severe demyelinations termed PSD3 and PSD4, with/without aqueous layers, respectively) are simulated using our previous multi-layered model of human motor nerve fibre. We studied the following parameters of myelinated axonal function: potentials (intracellular action, electrotonic-reflecting the propagating and accommodative fibre processes, respectively) and strength-duration time constants, rheobases, recovery cycles (reflecting the adaptive fibre processes). The results show that each excitability parameter is markedly potentiated when the aqueous layers within their paranodally demyelinated sheaths are taken into account. The effect of the aqueous layers is significantly higher on the propagating processes than on the accommodative and adaptive processes in the fibres. The aqueous layers restore the action potential propagation, which is initially blocked when they are not taken into account. The study provides new and important information on the mechanisms of chronic demyelinating neuropathies, such as chronic inflammatory demyelinating polyneuropathy (CIDP).
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Affiliation(s)
- D I Stephanova
- Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Sciences, Acad. G. Bontchev Str. Bl. 21, Sofia 1113, Bulgaria.
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Garces-Sanchez M, Laughlin RS, Dyck PJ, Engelstad JK, Norell JE, Dyck PJB. Painless diabetic motor neuropathy: a variant of diabetic lumbosacral radiculoplexus Neuropathy? Ann Neurol 2011; 69:1043-54. [PMID: 21425185 DOI: 10.1002/ana.22334] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 11/01/2010] [Accepted: 11/08/2010] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Occasionally, diabetic patients develop painless, lower-limb, motor predominant neuropathy. Whether this is a variant of diabetic lumbosacral radiculoplexus neuropathy (DLRPN) (a painful disorder from ischemic injury and microvasculitis), a variant of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) or another disorder is unsettled. Here, we characterize the clinical and pathological features of painless diabetic motor predominant neuropathy. METHODS We identified patients with this syndrome who underwent nerve biopsy. We compared pathological features to 33 DLRPN and 25 CIDP biopsies. RESULTS 23 patients were identified (22 had type 2 diabetes mellitus); 12 men; median age 62.2 years (range 36-78); median weight loss 30 pounds (range 0-100). Overall, the clinical features were similar to DLRPN except painless patients had more symmetrical and upper limb involvement, with slower progression and more severe impairment. Physiological testing demonstrated pan-modality sensory loss, autonomic abnormalities and axonal polyradiculoneuropathies. Nerve biopsies were similar to DLPRN showing ischemic injury (multifocal fiber loss [11/23], perineural thickening [18/23], injury neuroma [11/23], neovascularization [17/23]) and evidence of altered immunity and microvasculitis (epineurial perivascular inflammation [23/23], prior bleeding [11/23], vessel wall inflammation [15/23], and microvasculitis [3/23]). In contrast, CIDP biopsies did not show ischemic injury or microvasculitis but revealed demyelination and onion-bulbs. INTERPRETATION 1) Painless diabetic motor neuropathy is painless DLRPN and not CIDP and is caused by ischemic injury and microvasculitis. 2) The clinical features of painless DLRPN are different from typical DLPRN being more insidious and symmetrical with slower evolution. 3) The slower evolution may explain the lack of pain.
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Rajabally YA, Samarasekera S. Electrophysiological sensory demyelination in typical chronic inflammatory demyelinating polyneuropathy. Eur J Neurol 2010; 17:939-44. [PMID: 20158514 DOI: 10.1111/j.1468-1331.2010.02953.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The presence of electrophysiological demyelination of sensory nerves is not routinely assessed in the evaluation of suspected chronic inflammatory demyelinating polyneuropathy (CIDP). Whether this can be useful is unknown. METHODS We compared, using surface recording techniques, in 19 patients with typical CIDP and 26 controls with distal large fibre sensory axonal neuropathy, the forearm median sensory conductions, sensory nerve action potential (SNAP) amplitudes and durations and sensory nerve conduction velocities (SNCVs) of median, radial and sural nerves. RESULTS Median nerve sensory conduction block (SCB) across the forearm was greater in CIDP patients than in controls (P = 0.005). SNAP durations were longer in CIDP patients for median (P = 0.001) and sural nerves (P = 0.004). Receiver operating characteristic (ROC) curves provided sensitive (>40%) and specific (>95%) cut-offs for median nerve SCB as well as median and sural SNAP durations. SNCVs were significantly slower for median and sural nerves in CIDP patients, but ROC curves did not demonstrate cut-offs with useful sensitivities/specificities. Median SCB or prolonged median SNAP duration or prolonged sural SNAP duration offered a sensitivity of 73.7% for CIDP and specificity of 96.2%. Used as additional parameters, they improved diagnostic sensitivity of the American Academy of Neurology (AAN) criteria for CIDP of 1991, from 42.1% to 78.9% in this population, with preserved specificity of 100%. DISCUSSION Sensory electrophysiological demyelination is present and may be diagnostically useful in typical CIDP. SCB detection and SNAP duration prolongation appear to represent more useful markers of demyelination than SNCV reduction.
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Affiliation(s)
- Y A Rajabally
- Department of Neurology, Neuromuscular Clinic, University Hospitals of Leicester, Leicester, UK
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Tsukamoto H, Sonoo M, Shimizu T. Segmental evaluation of the peripheral nerve using tibial nerve SEPs for the diagnosis of CIDP. Clin Neurophysiol 2010; 121:77-84. [DOI: 10.1016/j.clinph.2009.09.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2009] [Revised: 08/21/2009] [Accepted: 09/17/2009] [Indexed: 11/28/2022]
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Laughlin RS, Dyck PJ, Melton LJ, Leibson C, Ransom J, Dyck PJB. Incidence and prevalence of CIDP and the association of diabetes mellitus. Neurology 2009; 73:39-45. [PMID: 19564582 PMCID: PMC2707109 DOI: 10.1212/wnl.0b013e3181aaea47] [Citation(s) in RCA: 200] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The reported prevalence of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) varies greatly, from 1.9 to 7.7 per 100,000. CIDP is reported to occur more commonly in patients with diabetes mellitus (DM) but has not been rigorously tested. OBJECTIVES To determine the incidence (1982-2001) and prevalence (on January 1, 2000) of CIDP in Olmsted County, Minnesota, and whether DM is more frequent in CIDP. METHODS CIDP was diagnosed by clinical criteria followed by review of electrophysiology. Cases were coded as definite, probable, or possible. DM was ascertained by clinical diagnosis or current American Diabetes Association glycemia criteria. RESULTS One thousand five hundred eighty-one medical records were reviewed, and 23 patients (10 women and 13 men) were identified as having CIDP (19 definite and 4 probable). The median age was 58 years (range 4-83 years), with a median disease duration at diagnosis of 10 months (range 2-64 months). The incidence of CIDP was 1.6/100,000/year. The prevalence was 8.9/100,000 persons on January 1, 2000. Only 1 of the 23 CIDP patients (4%) also had DM, whereas 14 of 115 age- and sex-matched controls (12%) had DM. CONCLUSIONS 1) The incidence (1.6/100,000/year) and prevalence (8.9/100,000) of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are similar to or higher than previous estimates. 2) The incidence of CIDP is similar to that of acute inflammatory demyelinating polyradiculoneuropathy within the same population. 3) Diabetes mellitus (DM) is unlikely to be a major risk covariate for CIDP, but we cannot exclude a small effect. 4) The perceived association of DM with CIDP may be due to misclassification of other forms of diabetic neuropathies and excessive emphasis on electrophysiologic criteria.
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Affiliation(s)
- R S Laughlin
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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Kim HJ, Jung CG, Jensen MA, Dukala D, Soliven B. Targeting of myelin protein zero in a spontaneous autoimmune polyneuropathy. THE JOURNAL OF IMMUNOLOGY 2009; 181:8753-60. [PMID: 19050296 DOI: 10.4049/jimmunol.181.12.8753] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Elimination of the costimulatory molecule B7-2 prevents autoimmune diabetes in NOD mice, but leads to the development of a spontaneous autoimmune polyneuropathy (SAP), which resembles the human disease chronic inflammatory demyelinating polyneuropathy (CIDP). In this study, we examined the immunopathogenic mechanisms in this model, including identification of SAP Ags. We found that B7-2-deficient NOD mice exhibit changes in cytokine and chemokine gene expression in spleens over time. There was an increase in IL-17 and a decrease in IL-10 transcript levels at 4 mo (preclinical phase), whereas IFN-gamma expression peaked at 8 mo (clinical phase). There was also an increase in transcript levels of Th1 cytokines, CXCL10, and RANTES in sciatic nerves of mice that developed SAP. Splenocytes from SAP mice exhibited proliferative and Th1 cytokine responses to myelin P0 (180-199), but not to other P0 peptides or P2 (53-78). Adoptive transfer of P0-reactive T cells generated from SAP mice induced neuropathy in four of six NOD.SCID mice. Data from i.v. tolerance studies indicate that myelin P0 is one of the autoantigens targeted by T cells in SAP in this model. The expression of P0 by peri-islet Schwann cells provides a potential mechanism linking islet autoimmunity and inflammatory neuropathy.
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Affiliation(s)
- Hye-Jung Kim
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
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Serrano-Castro PJ, Alonso-Verdegay G, López-Martínez G, Arjona-Padillo A, Callejón JR, Olmedo VM, Guardado-Santervás P, Huete-Hurtado A, Olivares-Romero J, Fernández CN. Possible case of peripheral osmotic demyelination syndrome. BMJ Case Rep 2009; 2009:bcr08.2008.0710. [PMID: 21686669 DOI: 10.1136/bcr.08.2008.0710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Central pontine myelinolysis (CPM) is an uncommon neurological syndrome that is usually related to the rapid restoration of a previous hyponatraemia. Although the most frequent location of CPM injury is the pons, it is now designated osmotic demyelination syndrome (ODS) because, as well as in the brainstem, these injuries can be observed in other parts of the central nervous system (CNS)-for example, the thalamus, subthalamic nucleus, external geniculate body, putamen, globus pallidum, internal capsule, white matter of cerebellum and the deep layers of the brain cortex. However, an exhaustive search of the literature (MEDLINE 1967-2007) has revealed no case report of peripheral nervous system (PNS) demyelination secondary to severe hyponatraemia.
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Affiliation(s)
- P J Serrano-Castro
- Unidad de Neurología Clínica y Diagnóstica, Hospital Torrecárdenas, Almería, Spain
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Abstract
Diabetes mellitus is associated with many different neuropathic syndromes, ranging from a mild sensory disturbance as can be seen in a diabetic sensorimotor polyneuropathy, to the debilitating pain and weakness of a diabetic lumbosacral radiculoplexus neuropathy. The etiology of these syndromes has been studied extensively, and may vary among metabolic, compressive, and immunological bases for the different disorders, as well as mechanisms yet to be discovered. Many of these disorders of nerve appear to be separate conditions with different underlying mechanisms, and some are caused directly by diabetes mellitus, whereas others are associated with it but not caused by hyperglycemia. This article discusses a number of the more common disorders of nerve found with diabetes mellitus. It discusses the symmetrical neuropathies, particularly generalized diabetic polyneuropathy, and then the focal or asymmetrical types of diabetes-associated neuropathy.
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Affiliation(s)
- Jennifer A Tracy
- Peripheral Neuropathy Research Laboratory, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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41
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Stephanova DI, Daskalova MS. Differences between the channels, currents and mechanisms of conduction slowing/block and accommodative processes in simulated cases of focal demyelinating neuropathies. EUROPEAN BIOPHYSICS JOURNAL: EBJ 2008; 37:829-42. [PMID: 18286274 DOI: 10.1007/s00249-008-0284-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Revised: 01/21/2008] [Accepted: 01/31/2008] [Indexed: 10/22/2022]
Abstract
To clarify the differences between the mechanisms of conduction slowing/block and accommodative processes in focal demyelinating neuropathies, this computational study presents the kinetics of the ionic, transaxonal and transmyelin currents defining the intracellular and electrotonic potentials in different segments of human motor nerve fibres. The computations use our previous double cable model of the fibres. The simulated fibres have focal demyelination of internodes, paranodes or both together. The intracellular potentials are defined mainly by the Na+ current, as the contribution of the K+ fast and K+ slow currents to the total nodal ionic current is negligible. The paranodal demyelinations cause an increase in the transaxonal current and a decrease in the transmyelin current at the paranodal segments. However, there is an inverse relationship between the transaxonal and transmyelin currents at the same segments in the cases of internodal demyelination. The internodal ionic channels beneath the myelin sheath do not contribute to the intracellular potentials, but they show a high sensitivity to long-lasting pulses. The slow components of the electrotonic potentials depend on the activation of the channel types in the nodal or internodal axolemma, whereas the fast components of the potentials are determined mainly by the passive cable responses. However, the current kinetics changes (defining the investigated electrotonic changes) are relatively weak. The study summarizes the results from these modelling investigations on the mechanisms underlying the conduction slowing/block and accommodative processes in focal demyelinating neuropathies such as Guillain-Barré syndrome and multifocal motor neuropathy.
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Affiliation(s)
- Diana I Stephanova
- Institute of Biophysics, Bulgarian Academy of Sciences, Acad. G. Bontchev Str., Bl. 21, Sofia, 1113, Bulgaria.
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Riccioli LA, D'Agostino V, Marliani A, Leonardi M. Massive Peripheral Nerve Hypertrophy in a Patient with Chronic Inflammatory Demyelinating Polyradiculoneuropathy. Neuroradiol J 2008; 21:107-9. [DOI: 10.1177/197140090802100115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Accepted: 07/20/2007] [Indexed: 11/17/2022] Open
Abstract
We describe a male patient with chronic inflammatory demyelinating polyradiculoneuropathy presenting extensive diffuse hypertrophy of the nerve roots of peripheral nerves. Since adolescence the patient has had a slow and progressive mainly distal loss of sensitivity and muscle weakness in all four limbs. He presented with diffuse muscle atrophy with enlarged palpable nerve trunks. Electromyography disclosed impaired sensory and motor responses in the bilateral median nerves and the right ulnar nerve. CSF examination showed elevated protein content, while MR scans depicted extensive hypertrophy of the spinal nerve roots. The patient benefitted from corticosteroid treatment.
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Affiliation(s)
| | - V. D'Agostino
- Chair in Neuroradiology, University of Naples; Naples, Italy
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Stephanova DI, Daskalova M, Alexandrov AS. Channels, currents and mechanisms of accommodative processes in simulated cases of systematic demyelinating neuropathies. Brain Res 2007; 1171:138-51. [PMID: 17706617 DOI: 10.1016/j.brainres.2007.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Revised: 07/06/2007] [Accepted: 07/12/2007] [Indexed: 11/16/2022]
Abstract
To clarify the mechanisms of accommodative processes in systematic demyelinating neuropathies, this study presents the kinetics of the ionic, transaxonal and transmyelin currents defining the electrotonic potentials in different segments of human demyelinated motor fibres. The electrotonic potentials are obtained for fibres, which are in simulated cases of internodal, paranodal and simultaneously of paranodal internodal demyelinations, each of them systematic. The computations used our previous double-cable model of the fibre. The results show that the slow components of the electrotonic potentials depend on the activation of the channel types in the nodal or internodal axolemma, whereas the fast components of the potentials are determined mainly by the passive cable responses, i.e. by the capacitances and resistances of the corresponding different segments along the fibre. In the nodal segments, the depolarizing electrotonus is determined mainly by the activation of the K(+) slow nodal channels, whereas in the paranodal and internodal segments the potentials depend on the activation of the K(+) fast and slow internodal channels. For the hyperpolarizing electrotonus, the contribution of the activating inward rectifier (IR) and leak (Lk) channels in the internodal axolemma dominates in the total ionic currents. The results show that the greater polarizing electrotonic potentials and their defining currents in the mild systematic demyelinations abnormally increase when these demyelinations are severe. The study summarizes the insights gained from these modeling investigations of the accommodative mechanisms underlying the threshold electrotonus abnormalities observed in demyelinating neuropathies such as Charcot-Marie-Tooth type 1A and chronic inflammatory demyelinating polyneuropathy.
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Affiliation(s)
- Diana I Stephanova
- Institute of Biophysics, Bulgarian Academy of Sciences, Sofia, Bulgaria.
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Stephanova D, Daskalova M. Membrane property abnormalities in simulated cases of mild systematic and severe focal demyelinating neuropathies. EUROPEAN BIOPHYSICS JOURNAL: EBJ 2007; 37:183-95. [PMID: 17786424 DOI: 10.1007/s00249-007-0215-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2007] [Revised: 07/27/2007] [Accepted: 08/03/2007] [Indexed: 10/22/2022]
Abstract
The investigation of multiple nerve membrane properties by mathematical models has become a new tool to study peripheral neuropathies. In demyelinating neuropathies, the membrane properties such as potentials (intracellular, extracellular, electrotonic) and indices of axonal excitability (strength-duration time constants, rheobases and recovery cycles) can now be measured at the peripheral nerves. This study provides numerical simulations of the membrane properties of human motor nerve fibre in cases of internodal, paranodal and simultaneously of paranodal internodal demyelinations, each of them mild systematic or severe focal. The computations use our previous multi-layered model of the fibre. The results show that the abnormally greater increase of the hyperpolarizing electrotonus, shorter strength-duration time constants and greater axonal superexcitability in the recovery cycles are the characteristic features of the mildly systematically demyelinated cases. The small decrease of the polarizing electrotonic responses in the demyelinated zone in turn leads to a compensatory small increase of these responses outside the demyelinated zone of all severely focally demyelinated cases. The paper summarizes the insights gained from these modeling studies on the membrane property abnormalities underlying the variation in clinical symptoms of demyelination in Charcot-Marie-Tooth disease type 1A, chronic inflammatory demyelinating polyneuropathy, Guillain-Barré syndrome and multifocal motor neuropathy. The model used provides an objective study of the mechanisms of these diseases which up till now have not been sufficiently well understood, because quite different assumptions have been given in the literature for the interpretation of the membrane property abnormalities obtained in hereditary, chronic and acquired demyelinating neuropathies.
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Affiliation(s)
- Diana Stephanova
- Institute of Biophysics, Bulgarian Academy of Sciences, Acad. G. Bontchev Str., Bl. 21, Sofia, 1113, Bulgaria.
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Lai WWL, Ubogu EE. Chronic inflammatory demyelinating polyradiculoneuropathy presenting as cauda equina syndrome in a diabetic. J Neurol Sci 2007; 260:267-70. [PMID: 17521674 DOI: 10.1016/j.jns.2007.04.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 04/15/2007] [Accepted: 04/17/2007] [Indexed: 10/23/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) may occur in association with diabetes mellitus (DM). We report a case of a poorly controlled diabetic patient who presented with rapid onset of bilateral lower extremity weakness and sensory loss associated with sacral and posterior thigh paresthesias and urinary and bowel incontinence, indicative of cauda equina syndrome (CES). Subsequent evaluation was consistent with CIDP. Monthly infusions with intravenous immunoglobulins (IVIg) with strict glycemic control using insulin resulted in remarkable clinical and electrophysiological recovery. This case report describes a rare presentation of CIDP and emphasizes the importance of early utility of electrodiagnostic (EDX) studies in the clinical evaluation of diabetic patients presenting with rapidly progressive lower extremity weakness and sensory loss associated with diminished reflexes.
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Affiliation(s)
- Wayne W L Lai
- Neurology Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106-1703, United States
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46
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Rajabally YA, Narasimhan M. The value of sensory electrophysiology in chronic inflammatory demyelinating polyneuropathy. Clin Neurophysiol 2007; 118:1999-2004. [PMID: 17644033 DOI: 10.1016/j.clinph.2007.06.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2007] [Revised: 05/13/2007] [Accepted: 06/10/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the usefulness of sensory nerve conduction studies in comparison and in combination with motor conductions in diagnosing chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS We retrospectively compared the electrophysiology of 20 patients with CIDP to that of 20 controls with axonal polyneuropathy, and 20 controls with myopathy. Five sensory abnormality patterns were evaluated. RESULTS The "abnormal radial normal sural" ("ARNS") pattern showed a sensitivity of 25% for CIDP and specificity of 100% versus axonal neuropathies (p=0.047). The "abnormal sural normal radial" ("ASNR") pattern had a sensitivity of 75% for axonal neuropathy with a specificity of 80% versus CIDP (p=0.0012). Presence of ARNS or absence of ASNR patterns showed equivalent or superior sensitivity and specificity to most individual motor demyelinating defects for CIDP. Presence of ARNS or absence of ASNR patterns, integrated within three different sets of electrodiagnostic criteria for CIDP, increased sensitivity in all without significantly altering specificity. Effects were most remarkable with the American Academy of Neurology criteria (1991), which showed significantly improved sensitivity (50-85%; p=0.041), with preserved specificity of 100%. CONCLUSIONS The use of sensory abnormality patterns appears justified in comparison and combination with motor defects in diagnosing CIDP. SIGNIFICANCE Sensory studies may be useful in contributing to the electrodiagnosis of CIDP and their inclusion in existing electrodiagnostic criteria deserves consideration.
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Affiliation(s)
- Yusuf A Rajabally
- Neuromuscular Clinic, Department of Neurology, University Hospitals of Leicester, Leicester, UK.
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Kalita J, Misra UK, Yadav RK. A comparative study of chronic inflammatory demyelinating polyradiculoneuropathy with and without diabetes mellitus. Eur J Neurol 2007; 14:638-43. [PMID: 17539941 DOI: 10.1111/j.1468-1331.2007.01798.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Diabetes mellitus (DM) is occasionally associated with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) raising the question of coexistence or etiological link. The study compares, neurophysiological and outcome of CIDP patients with and without DM. Consecutive CIDP patients were subjected to detailed clinical evaluation, haematology, serum chemistry, vasculitis profile, paraproteins, myeloma screening and cerebrospinal fluid (CSF) examination. Electrodiagnostic (EDx) tests included motor and sensory conduction and F-wave studies. The patients were treated with oral prednisolone 1 mg/kg/day with or without azathioprine 1-2 mg/kg and followed up for 6 months. The clinical and EDx finding in CIDP with and without DM were compared. Thirty-five CIDP patients were included and nine had DM. CIDP with diabetes (CIDP-D) had higher frequency of autonomic dysfunction. In CIDP-D, motor (38.9% vs. 16.7%) and sensory (40.7% vs. 14.1%) nerve conductions were more frequently unrecordable or had reduced compound muscle action potential (CMAP) amplitude. F-waves were also more frequently unrecordable in CIDP-D (28.8% vs. 12.8%) compared with idiopathic CIDP (I-CIDP). The degree of conduction block was more in I-CIDP. At 6-month follow up, I-CIDP patients improved better than CIDP-D. CIDP-D patients present with higher frequency of autonomic dysfunction, electrophysiological evidences of associated axonal loss and had a poorer outcome at 6 months compared with I-CIDP.
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Affiliation(s)
- J Kalita
- Department of Neurology, Sanjay Gandhi PGIMS, Lucknow, India
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Stephanova DI, Alexandrov AS. Simulating mild systematic and focal demyelinating neuropathies: membrane property abnormalities. J Integr Neurosci 2007; 5:595-623. [PMID: 17245824 DOI: 10.1142/s0219635206001331] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Accepted: 11/15/2006] [Indexed: 11/18/2022] Open
Abstract
This study provides numerical simulations of some of the abnormalities in the potentials and axonal excitability indices of human motor nerve fibers in simulated cases of internodal, paranodal and simultaneously of paranodal internodal demyelinations, each of them systematic or focal. A 70% reduction of the myelin lamellae (defining internodal demyelination), or of the paranodal seal resistance (defining paranodal demyelination), or simultaneously both of them (defining paranodal internodal demyelination) was uniform along the fiber length for the systematically demyelinated subtypes. These permutations were termed internodal systematic demyelination (ISD), paranodal systematic demyelination (PSD) and paranodal internodal systematic demyelination (PISD). In other tests, the same reductions of the myelin sheath parameters were used but restricted to only three (8th, 9th and 10th) consecutive internodes. Such fiber demyelinations were termed internodal focal demyelination (IFD), paranodal focal demyelination (PFD) and paranodal internodal focal demyelination (PIFD). The computations used our previous double cable model of the fibers. The axon model was comprised of 30 nodes and 29 internodes. The 70% reduction value was not sufficient to develop conduction block in all investigated demyelinations, which were regarded as mild. The membrane property abnormalities obtained in the ISD, PSD and PISD cases were quite different and abnormally greater than those in the IFD, PFD and PIFD cases. The changes in the excitability indices such as strength-duration time constants, rheobasic currents and recovery cycles in the focally demyelinated subtypes were so slight as to be essentially indistinguishable from normal values. Consequently, the excitability based approaches that have shown strong potential as diagnostic tools in systematically demyelinated conditions may not be useful in detecting mild focal demyelinations. The membrane property changes simulated in the systematically demyelinated subtypes are in good accordance with the data from patients with Charcot-Marie-Tooth disease type 1A (CMT1A) and chronic inflammatory demyelinating polyneuropathy (CIDP). The excitability abnormalities obtained in each focally demyelinated subtype match those observed in vivo in patients with demyelinating forms of Guillain-Barré syndrome (GBS). The results indicate that the model that was used is a rather promising tool in studying the membrane property abnormalities of hereditary, chronic and acquired demyelinating neuropathies, which up till now, have not been sufficiently well understood.
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Affiliation(s)
- D I Stephanova
- Institute of Biophysics, Bulgarian Academy of Sciences, Acad. G. Bontchev Str., Bl. 21, Sofia 1113, Bulgaria.
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Münch C, Anagnostou P, Meyer R, Haas J. Rituximab in chronic inflammatory demyelinating polyneuropathy associated with diabetes mellitus. J Neurol Sci 2007; 256:100-2. [PMID: 17382963 DOI: 10.1016/j.jns.2007.02.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Revised: 02/16/2007] [Accepted: 02/19/2007] [Indexed: 11/29/2022]
Abstract
The authors report a 57-year-old patient with chronic inflammatory demyelinating polyneuropathy (CIDP) associated with diabetes mellitus (DM) who was treated successfully with rituximab. The B lymphocyte suppression using rituximab was followed 4 weeks later by neurological improvement and a stable disease course of over 10 months. We suggest that rituximab may be a treatment option in CIDP increasingly less responsive to intravenous immunoglobulin, particularly in patients with concurrent DM.
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Affiliation(s)
- Christoph Münch
- Department of Neurology, Jewish Hospital Berlin, Berlin, Germany.
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Stephanova DI, Alexandrov AS, Kossev A, Christova L. Simulating focal demyelinating neuropathies: membrane property abnormalities. BIOLOGICAL CYBERNETICS 2007; 96:195-208. [PMID: 17072638 DOI: 10.1007/s00422-006-0113-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2006] [Accepted: 09/16/2006] [Indexed: 05/12/2023]
Abstract
Membrane properties such as potentials (intracellular, extracellular, electrotonic) and axonal excitability indices (strength-duration and charge-duration curves, strength-duration time constants, rheobasic currents, recovery cycles) can now be measured in healthy subjects and patients with demyelinating neuropathies. They are regarded here in two cases of simultaneously reduced paranodal seal resistance and myelin lamellae in one to three consecutive internodes of human motor nerve fiber. The investigations are performed for 70 and 96% myelin reduction values. The first value is not sufficient to develop a conduction block, but the second leads to a block and the corresponding demyelinations are regarded as mild and severe. For both the mild and severe demyelinations, the paranodally internodally focally demyelinated cases (termed as PIFD1, PIFD2, and PIFD3, respectively, with one, two, and three demyelinated internodes) are simulated using our previous double-cable model of the fiber. The axon model consists of 30 nodes and 29 internodes. The membrane property abnormalities obtained can be observed in vivo in patients with demyelinating forms of Guillain-Barré syndrome (GBS) and multifocal motor neuropathy (MMN). The study confirms that focal demyelinations are specific indicators for acquired demyelinating neuropathies. Moreover, the following changes have been calculated in our previous papers: (1) uniform reduction of myelin thickness in all internodes (Stephanova et al. in Clin Neurophysiol 116: 1153-1158, 2005); (2) demyelination of all paranodal regions (Stephanova and Daskalova in Clin Neurophysiol 116: 1159-1166, 2005a); (3) simultaneous reduction of myelin thickness and paranodal demyelination in all internodes (Stephanova and Daskalova in Clin Neurophysiol 116: 2334-2341, 2005b); and (4) reduction of myelin thickness of up to three internodes (Stephanova et al., in J Biol Phys, 2006a,b, DOI: 10.1007/s10867-005-9001-9; DOI: 10.1007/s10867-006-9008-x). The membrane property abnormalities obtained in the homogeneously demyelinated cases are quite different and abnormally greater than those in the case investigated here of simultaneous reduction in myelin thickness and paranodal demyelination of up to three internodes. Our previous and present results show that unless focal demyelination is severe enough to cause outright conduction block, changes are so slight as to be essentially indistinguishable from normal values. Consequently, the excitability-based approaches that have shown strong potential as diagnostic tools in systematically demyelinated conditions may not be useful in detecting mild focal demyelinations, independently of whether they are internodal, paranodal, or paranodal internodal.
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Affiliation(s)
- D I Stephanova
- Institute of Biophysics, Bulgarian Academy of Sciences, Acad. G. Bontchev Str., Bl. 21, Sofia 1113, Bulgaria.
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